A Case of Henoch-Schönlein Purpura on Endoscopy: 1862

Vasculitis of Gastrointestinal (GI) tract presents with abdominal pain, nausea, vomiting, and bleeding. It is difficult to diagnose vasculitis through endoscopy due to low diagnostic yield of endoscopic biopsies and therefore it is important to consider clinical feature. We present a case of IgA vasculitis involving GI tract, emphasizing role of multidisciplinary approach. A 77 years old man with medical history of Grave's disease, atrial fibrillation, osteoarthritis, gout, and hypertension presented to Emergency Room due to worsening abdominal pain, nausea, vomiting, and blood in stool. Patient reported abdominal pain for 3 weeks, diffuse and dull and becoming periumbilical and reproducible without any relieving or exacerbating factors. He reported early satiety without weight loss. Complete metabolic panel (CMP) and complete blood count (CBC), and Lactic Acid were normal however patient had 2gram urine protein. He had periumbilical tenderness and bilateral lower extremities pitting edema with purpuric patches. Abdomen and Pelvic CT scan showed nonspecific wall thickening of distal esophagus, stomach, cecum, distal ileum, and small segment of jejunum. On Enteroscopy nodular appearing fundic mucosa with ulcerations was seen, biopsy showed ischemic gastropathy. Second portion of Duodenum showed nodular appearing mucosa while Third portion showed an ulcerated duodenal lesion which was biopsied and showed ulcer with acute duodenitis. Proximal Jejunum was normal however ulceration with surrounding erythema was noted distally and biopsy showed ulcerative jejunitis. Colonoscopy showed scattered areas of ulceration and erythema extending from rectum to terminal ileum which was biopsied and showed features of resolving acute ischemia. Rheumatology was consulted and punch biopsy from lower extremity showed granular deposit of IgA surrounding superficial dermal vessel compatible with Henoch-Schönlein Purpura. Renal biopsy showed focal mesangial proliferation with segmental inflammatory glomerulopathy with sclerosis consistent with IgA nephropathy. Patient was started on high dose steroids 80mg/day. Renal function was followed and was stable therefore steroids were tapered off. Patient underwent repeat Colonoscopy and Enteroscopy after 1 year of being off of steroids which showed normal mucosa. Our case highlights difficulty in diagnosing vasculitis through endoscopy and shows clinical course of vasculitis of GI tract through follow-up endoscopy.